Part 6 Awareness Raising, Screening and Assessment of Falls Risk
Part 6 Awareness Raising Screening and Assessment of
Falls Risk
51Queensland Stay On Your Feetreg community good practice guidelines
Awareness Raising Screening and Assessment of 6 Falls Risk
Measurement of Falls Risk61
There are a substantial number of falls risk measurement tools that
have evidence to support their reliability and validity [132] However
there is at present no tool that can be applied across all settings
Also of the existing tools few have been validated in more than one
setting [133] In the community setting there should be available a
falls risk tool that can be used with confidence as an initial step to
developing an individualised falls prevention program Consequently
there should be little need to develop new tools In fact further
development of fall risk tools unique to individual programsfacilities
may be counterproductive because scores will not be comparable
across programsfacilities [132]
Purpose of Measurement of Falls Risk 62
The purpose of measurement may be
Awareness raising to examine an individualrsquos awareness of falls Eacute
andor knowledge of risk factors
Screening to determine an individualrsquos level of risk for falls Eacute
Assessment to examine an individualrsquos risk factor profile and Eacute
determine referral pathways and appropriate interventions
Falls Risk Awareness621
Falls risk awareness tools are generally designed as an education
resource to raise awareness of risk of falls and alert the person to take
remedial action andor seek professional advice They often take the
form of a checklist with action plan and are self-administered They
may also be used to test knowledge of community-dwelling older
people andor health care workers about falls and risk factors in order
52 Queensland Stay On Your Feetreg community good practice guidelines
to determine the need for or to evaluate the impact of an education
intervention (Section 651 provides examples)
Falls Risk Screening622
While there is not a definitive difference between screening and
assessment tools screening is a process that is assumed to be less
detailed and may precede assessment [3] A falls risk screen is the
minimum process to determine which older people are at greatest risk
of falling Typically the screen consists of a small number of items (up
to five) based on presence or absence of a risk factor Since one of
the strongest risk factors for falling is having had a previous fall [129]
a minimum falls risk screen would be a single item question lsquoHave
you had a fall in the last 12 monthsrsquo Risk factors that form part of a
screening tool may not necessarily be those that can be modified to
reduce the risk of falls When the threshold score on a falls screening is
exceeded it would prompt a more detailed falls risk assessment
Falls Risk Assessment623
Falls risk assessment is a more detailed and systematic process than
screening It is used to identify modifiable factors that contribute to a
personrsquos increased risk of falling and to develop an individualised plan
focussed on prevention of falls The implicit assumption underlying the
concept of assessment of risk is that early detection and intervention
(that occurs before overt development of the disorder or adverse event)
will lead to a more favourable prognosis or outcome
There is a continuum of falls risk from lsquono riskrsquo through to lsquovery
high riskrsquo A graded individual falls risk assessment provides the
opportunity for primary health care professional to identify risk early
and intervene before the risk factor has become moderately advanced
Potentially better health outcomes will be achieved through early
identification and intervention
53Queensland Stay On Your Feetreg community good practice guidelines
Summary of Falls Risk Measurement 624
The circumstances and purpose for which falls risk measurement is
undertaken are illustrated in Table 61
Table 6‑1 Falls Risk Measurement
Tool Who Administers
Setting3 Purpose
Falls Risk Awareness
Self-administered
Community to educate and raise awareness
to trigger self-referral Eacuteto seek professional advice
to test knowledge Eacutepre-post intervention
Falls Risk Screening
Health Professional
Primary Health Care
to determine those Eacuteat high risk
to determine those Eacutewho warrant more detailed assessment
Falls Risk Assessment
Health Professional
Primary Health Care
to identify Eacutemodifiable risk factors
to target and tailor Eacuteinterventions
to implement Eacutefalls and injury risk management strategies for individuals identified with high risk of fall
3 For community-dwelling older people their first level of care will be in the primary health care setting See GLOSSARY for definition
54 Queensland Stay On Your Feetreg community good practice guidelines
General Principles of Screening and Assessment 63
The prevalence of the pre-clinical condition (or risk factors) should
be relatively high among the population If the prevalence of the risk
factor is low (or the intervention reaches and changes the risk factors
of a limited proportion of the population) there will be little impact at
the population level [80]
The resources for conducting risk measurement must be cost effective
and the expenses justifiable in terms of ameliorating adverse health
consequences Ethical issues should also be considered such as
availability and equity of access for the at-risk population [134]
A suitable test must be available cost effective easy to administer
and impose minimal demands or discomfort on those tested The
results must be valid reliable and reproducible [134] A number of
measurement tools that meet these criteria are listed under Section 65
Effective treatmentinterventionscare plans need to be available and
evidence-based There must be a follow-up intervention based on
assessment [134]
Case For and Against Falls Screening and 631 Assessment
On the basis of the principles outlined in Section 63 there is intuitive
appeal for falls risk screening and assessment as a public health
measure However there is still debate about its value particularly for
population-based screening of community-dwelling older people
In support of falls screening and assessment
All older people should have documentation that they were asked Eacute
at least annually about the occurrence of recent falls because falls
are common often preventable and frequently unreported [129 135]
One of the strongest predictors of a future fall is having a previous
fall but only a third of older fallers report their falls to a health
professional [58]
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
51Queensland Stay On Your Feetreg community good practice guidelines
Awareness Raising Screening and Assessment of 6 Falls Risk
Measurement of Falls Risk61
There are a substantial number of falls risk measurement tools that
have evidence to support their reliability and validity [132] However
there is at present no tool that can be applied across all settings
Also of the existing tools few have been validated in more than one
setting [133] In the community setting there should be available a
falls risk tool that can be used with confidence as an initial step to
developing an individualised falls prevention program Consequently
there should be little need to develop new tools In fact further
development of fall risk tools unique to individual programsfacilities
may be counterproductive because scores will not be comparable
across programsfacilities [132]
Purpose of Measurement of Falls Risk 62
The purpose of measurement may be
Awareness raising to examine an individualrsquos awareness of falls Eacute
andor knowledge of risk factors
Screening to determine an individualrsquos level of risk for falls Eacute
Assessment to examine an individualrsquos risk factor profile and Eacute
determine referral pathways and appropriate interventions
Falls Risk Awareness621
Falls risk awareness tools are generally designed as an education
resource to raise awareness of risk of falls and alert the person to take
remedial action andor seek professional advice They often take the
form of a checklist with action plan and are self-administered They
may also be used to test knowledge of community-dwelling older
people andor health care workers about falls and risk factors in order
52 Queensland Stay On Your Feetreg community good practice guidelines
to determine the need for or to evaluate the impact of an education
intervention (Section 651 provides examples)
Falls Risk Screening622
While there is not a definitive difference between screening and
assessment tools screening is a process that is assumed to be less
detailed and may precede assessment [3] A falls risk screen is the
minimum process to determine which older people are at greatest risk
of falling Typically the screen consists of a small number of items (up
to five) based on presence or absence of a risk factor Since one of
the strongest risk factors for falling is having had a previous fall [129]
a minimum falls risk screen would be a single item question lsquoHave
you had a fall in the last 12 monthsrsquo Risk factors that form part of a
screening tool may not necessarily be those that can be modified to
reduce the risk of falls When the threshold score on a falls screening is
exceeded it would prompt a more detailed falls risk assessment
Falls Risk Assessment623
Falls risk assessment is a more detailed and systematic process than
screening It is used to identify modifiable factors that contribute to a
personrsquos increased risk of falling and to develop an individualised plan
focussed on prevention of falls The implicit assumption underlying the
concept of assessment of risk is that early detection and intervention
(that occurs before overt development of the disorder or adverse event)
will lead to a more favourable prognosis or outcome
There is a continuum of falls risk from lsquono riskrsquo through to lsquovery
high riskrsquo A graded individual falls risk assessment provides the
opportunity for primary health care professional to identify risk early
and intervene before the risk factor has become moderately advanced
Potentially better health outcomes will be achieved through early
identification and intervention
53Queensland Stay On Your Feetreg community good practice guidelines
Summary of Falls Risk Measurement 624
The circumstances and purpose for which falls risk measurement is
undertaken are illustrated in Table 61
Table 6‑1 Falls Risk Measurement
Tool Who Administers
Setting3 Purpose
Falls Risk Awareness
Self-administered
Community to educate and raise awareness
to trigger self-referral Eacuteto seek professional advice
to test knowledge Eacutepre-post intervention
Falls Risk Screening
Health Professional
Primary Health Care
to determine those Eacuteat high risk
to determine those Eacutewho warrant more detailed assessment
Falls Risk Assessment
Health Professional
Primary Health Care
to identify Eacutemodifiable risk factors
to target and tailor Eacuteinterventions
to implement Eacutefalls and injury risk management strategies for individuals identified with high risk of fall
3 For community-dwelling older people their first level of care will be in the primary health care setting See GLOSSARY for definition
54 Queensland Stay On Your Feetreg community good practice guidelines
General Principles of Screening and Assessment 63
The prevalence of the pre-clinical condition (or risk factors) should
be relatively high among the population If the prevalence of the risk
factor is low (or the intervention reaches and changes the risk factors
of a limited proportion of the population) there will be little impact at
the population level [80]
The resources for conducting risk measurement must be cost effective
and the expenses justifiable in terms of ameliorating adverse health
consequences Ethical issues should also be considered such as
availability and equity of access for the at-risk population [134]
A suitable test must be available cost effective easy to administer
and impose minimal demands or discomfort on those tested The
results must be valid reliable and reproducible [134] A number of
measurement tools that meet these criteria are listed under Section 65
Effective treatmentinterventionscare plans need to be available and
evidence-based There must be a follow-up intervention based on
assessment [134]
Case For and Against Falls Screening and 631 Assessment
On the basis of the principles outlined in Section 63 there is intuitive
appeal for falls risk screening and assessment as a public health
measure However there is still debate about its value particularly for
population-based screening of community-dwelling older people
In support of falls screening and assessment
All older people should have documentation that they were asked Eacute
at least annually about the occurrence of recent falls because falls
are common often preventable and frequently unreported [129 135]
One of the strongest predictors of a future fall is having a previous
fall but only a third of older fallers report their falls to a health
professional [58]
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
52 Queensland Stay On Your Feetreg community good practice guidelines
to determine the need for or to evaluate the impact of an education
intervention (Section 651 provides examples)
Falls Risk Screening622
While there is not a definitive difference between screening and
assessment tools screening is a process that is assumed to be less
detailed and may precede assessment [3] A falls risk screen is the
minimum process to determine which older people are at greatest risk
of falling Typically the screen consists of a small number of items (up
to five) based on presence or absence of a risk factor Since one of
the strongest risk factors for falling is having had a previous fall [129]
a minimum falls risk screen would be a single item question lsquoHave
you had a fall in the last 12 monthsrsquo Risk factors that form part of a
screening tool may not necessarily be those that can be modified to
reduce the risk of falls When the threshold score on a falls screening is
exceeded it would prompt a more detailed falls risk assessment
Falls Risk Assessment623
Falls risk assessment is a more detailed and systematic process than
screening It is used to identify modifiable factors that contribute to a
personrsquos increased risk of falling and to develop an individualised plan
focussed on prevention of falls The implicit assumption underlying the
concept of assessment of risk is that early detection and intervention
(that occurs before overt development of the disorder or adverse event)
will lead to a more favourable prognosis or outcome
There is a continuum of falls risk from lsquono riskrsquo through to lsquovery
high riskrsquo A graded individual falls risk assessment provides the
opportunity for primary health care professional to identify risk early
and intervene before the risk factor has become moderately advanced
Potentially better health outcomes will be achieved through early
identification and intervention
53Queensland Stay On Your Feetreg community good practice guidelines
Summary of Falls Risk Measurement 624
The circumstances and purpose for which falls risk measurement is
undertaken are illustrated in Table 61
Table 6‑1 Falls Risk Measurement
Tool Who Administers
Setting3 Purpose
Falls Risk Awareness
Self-administered
Community to educate and raise awareness
to trigger self-referral Eacuteto seek professional advice
to test knowledge Eacutepre-post intervention
Falls Risk Screening
Health Professional
Primary Health Care
to determine those Eacuteat high risk
to determine those Eacutewho warrant more detailed assessment
Falls Risk Assessment
Health Professional
Primary Health Care
to identify Eacutemodifiable risk factors
to target and tailor Eacuteinterventions
to implement Eacutefalls and injury risk management strategies for individuals identified with high risk of fall
3 For community-dwelling older people their first level of care will be in the primary health care setting See GLOSSARY for definition
54 Queensland Stay On Your Feetreg community good practice guidelines
General Principles of Screening and Assessment 63
The prevalence of the pre-clinical condition (or risk factors) should
be relatively high among the population If the prevalence of the risk
factor is low (or the intervention reaches and changes the risk factors
of a limited proportion of the population) there will be little impact at
the population level [80]
The resources for conducting risk measurement must be cost effective
and the expenses justifiable in terms of ameliorating adverse health
consequences Ethical issues should also be considered such as
availability and equity of access for the at-risk population [134]
A suitable test must be available cost effective easy to administer
and impose minimal demands or discomfort on those tested The
results must be valid reliable and reproducible [134] A number of
measurement tools that meet these criteria are listed under Section 65
Effective treatmentinterventionscare plans need to be available and
evidence-based There must be a follow-up intervention based on
assessment [134]
Case For and Against Falls Screening and 631 Assessment
On the basis of the principles outlined in Section 63 there is intuitive
appeal for falls risk screening and assessment as a public health
measure However there is still debate about its value particularly for
population-based screening of community-dwelling older people
In support of falls screening and assessment
All older people should have documentation that they were asked Eacute
at least annually about the occurrence of recent falls because falls
are common often preventable and frequently unreported [129 135]
One of the strongest predictors of a future fall is having a previous
fall but only a third of older fallers report their falls to a health
professional [58]
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
53Queensland Stay On Your Feetreg community good practice guidelines
Summary of Falls Risk Measurement 624
The circumstances and purpose for which falls risk measurement is
undertaken are illustrated in Table 61
Table 6‑1 Falls Risk Measurement
Tool Who Administers
Setting3 Purpose
Falls Risk Awareness
Self-administered
Community to educate and raise awareness
to trigger self-referral Eacuteto seek professional advice
to test knowledge Eacutepre-post intervention
Falls Risk Screening
Health Professional
Primary Health Care
to determine those Eacuteat high risk
to determine those Eacutewho warrant more detailed assessment
Falls Risk Assessment
Health Professional
Primary Health Care
to identify Eacutemodifiable risk factors
to target and tailor Eacuteinterventions
to implement Eacutefalls and injury risk management strategies for individuals identified with high risk of fall
3 For community-dwelling older people their first level of care will be in the primary health care setting See GLOSSARY for definition
54 Queensland Stay On Your Feetreg community good practice guidelines
General Principles of Screening and Assessment 63
The prevalence of the pre-clinical condition (or risk factors) should
be relatively high among the population If the prevalence of the risk
factor is low (or the intervention reaches and changes the risk factors
of a limited proportion of the population) there will be little impact at
the population level [80]
The resources for conducting risk measurement must be cost effective
and the expenses justifiable in terms of ameliorating adverse health
consequences Ethical issues should also be considered such as
availability and equity of access for the at-risk population [134]
A suitable test must be available cost effective easy to administer
and impose minimal demands or discomfort on those tested The
results must be valid reliable and reproducible [134] A number of
measurement tools that meet these criteria are listed under Section 65
Effective treatmentinterventionscare plans need to be available and
evidence-based There must be a follow-up intervention based on
assessment [134]
Case For and Against Falls Screening and 631 Assessment
On the basis of the principles outlined in Section 63 there is intuitive
appeal for falls risk screening and assessment as a public health
measure However there is still debate about its value particularly for
population-based screening of community-dwelling older people
In support of falls screening and assessment
All older people should have documentation that they were asked Eacute
at least annually about the occurrence of recent falls because falls
are common often preventable and frequently unreported [129 135]
One of the strongest predictors of a future fall is having a previous
fall but only a third of older fallers report their falls to a health
professional [58]
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
54 Queensland Stay On Your Feetreg community good practice guidelines
General Principles of Screening and Assessment 63
The prevalence of the pre-clinical condition (or risk factors) should
be relatively high among the population If the prevalence of the risk
factor is low (or the intervention reaches and changes the risk factors
of a limited proportion of the population) there will be little impact at
the population level [80]
The resources for conducting risk measurement must be cost effective
and the expenses justifiable in terms of ameliorating adverse health
consequences Ethical issues should also be considered such as
availability and equity of access for the at-risk population [134]
A suitable test must be available cost effective easy to administer
and impose minimal demands or discomfort on those tested The
results must be valid reliable and reproducible [134] A number of
measurement tools that meet these criteria are listed under Section 65
Effective treatmentinterventionscare plans need to be available and
evidence-based There must be a follow-up intervention based on
assessment [134]
Case For and Against Falls Screening and 631 Assessment
On the basis of the principles outlined in Section 63 there is intuitive
appeal for falls risk screening and assessment as a public health
measure However there is still debate about its value particularly for
population-based screening of community-dwelling older people
In support of falls screening and assessment
All older people should have documentation that they were asked Eacute
at least annually about the occurrence of recent falls because falls
are common often preventable and frequently unreported [129 135]
One of the strongest predictors of a future fall is having a previous
fall but only a third of older fallers report their falls to a health
professional [58]
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
55Queensland Stay On Your Feetreg community good practice guidelines
Many previously undetected remediable problems including falls Eacute
can be identified among apparently healthy older individuals in
community geriatric screening programs [136] Multiple falls can
be strong indicators of accelerating frailty and the presence of
underlying treatable risk factors [135] The high prevalence of under-
diagnosed and under-treated health-related conditions in older
people has motivated the development of specialised geriatric
screening and assessment programs [137]
Early identification of risk factors allows detection of impairments Eacute
before a serious injury secondary deconditioning or loss of
confidence in mobility can occur [58] and relevant changes can be
monitored over time [138]
Identification of risk factors provides direction for appropriate Eacute
referrals and is the cornerstone of most preventing fall
programs [63 139]
Use of standard protocols for assessing risk can improve Eacute
communication as well as allow a common language around the
concepts of functional ability care planning reporting and service
planning [138]
Although there is limited evidence in the area of preventing falls Eacute
early detection of risk and early intervention in a number of health
areas has been shown to improve longer term outcomes
Risk assessment identifies a personrsquos needs at a specific time and Eacute
can be used to reassess their needs as they change over time
In opposition to falls screening and assessment
Falls risk screening need not be applied universally to everyone it Eacute
can still be based on criteria such as a recent fall which reduces the
resource demand of the approach
Falls screening and assessment alone will not preventreduce falls Eacute
and undue emphasis may be placed on assessment rather than the
consequent action plan
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
56 Queensland Stay On Your Feetreg community good practice guidelines
A diagnosis of high fall risk may stigmatise an older person and Eacute
raise levels of fear of falling
Most of the current activity in preventing falls is based on the Eacute
medical model of individual clinical assessment proximate to the
time of risk [30] Traditional medical model approaches aimed at
screening and treating risk factors are often too late for the purposes
of prevention [140]
Individually-based assessment and treatment may be effective in Eacute
reducing an individualrsquos risk of falling but it does little to reduce the
population burden of risk [80]
Screening of high-risk populations to predict risk of falling is of Eacute
limited use [133] because it could be argued that all older people are
at risk Population-based interventions on unselected populations
use a public health model that aims to prevent adverse health in all
who may be susceptible [141]
There may not be an assessment tool that can apply to all Eacute
community-dwelling older people [133]
Risk assessment needs to be repeated and this can be seen as Eacute
consuming additional resources
Evidence‑Based Measures 64
Falls Risk Awareness Measures641
While a number of studies have been undertaken on awareness
knowledge attitudes andor information needs of older community-
dwelling people concerning falls awareness tools used have not
usually been subjected to rigorous review Examples of these resources
can be found in Section 651
Falls Risk Screening and Assessment Measures 642
A number of falls risk screening and assessment tools have been
developed Reviews of these tools [132 133 142 143] have focussed on acute
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
57Queensland Stay On Your Feetreg community good practice guidelines
care and institutional settings with little attention to tools tested in
community settings [133]
The main evidence supporting falls risk screening and assessment
comes from reviews of falls prevention interventions Assessment
as part of a multifactorial approach for the prevention of falls is
supported by evidence of strong associations between multiple risk
factors and falls as well as from experimental studies demonstrating
significant fall reductions where assessment is combined with tailored
interventions [144]
Assessment of falls risk typically involves either the use of
multifactorial assessment tools that cover a wide range of fall-risk
factors or functional mobility assessments that typically focus on the
physiological and functional domains of postural stability [133]
The multifactorial assessment tools consist of a checklist comprising
questions used to screen the level and nature of risk based on a
combined score of multiple factors known to be associated with
fall-related risk [133] A comprehensive multidimensional fall risk
assessment may include the following
a history of fall circumstances and medical problems Eacute
review of medications Eacute
mobility assessment Eacute
an examination of vision gait and balance and lower extremity joint Eacute
function
a basic neurological examination Eacute
testing of psychological and mental status Eacute
the assessment of cardiovascular status Eacute
an assessment of foot problems and footwear Eacute
an assessment of continence Eacute
an assessment of environmental risk factors or home hazards Eacute
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
58 Queensland Stay On Your Feetreg community good practice guidelines
Other components of the fall risk assessment can include functional
performance tests and an environmental assessment of the
individualrsquos living circumstances [129]
Functional mobility assessment tools typically include simple
performance-based tests of gait balance mobility strength and
reaction times such as the Timed Up-and-Go test the alternate step
sit-to-stand test with five repetitions and the six metre walk and
functional reach [145] (See section 652 for more details on these tools)
Both types of tools may be designed as a quick screen for determining
high risk or to target specific factors for risk reduction - either may
trigger referral for further investigation and testing [133]
To meet the lsquoGold Standard Criteriarsquo for quality [133] risk assessment
tools should
be validated in prospective studies Eacute
have sufficient data to calculate sensitivity specificity positive and Eacute
negative predictive values
be validated in more than one population setting Eacute
demonstrate good face validity Eacute
demonstrate good inter-rater reliability Eacute
have good adherence from staff Eacute
have clear instructions and allow a score to be easily calculated Eacute
have a grading of risk on a particular risk factor (rather than just a Eacute
yes or no response) as this is better for identifying mild levels of risk
have clear guidelines associated that provide recommendations Eacute
for management strategies for specific risk factors and level of risk
identified
Risk assessment tools should also be described in peer-reviewed
journals At present there is no tool that can be applied reliably across
different settings or for subpopulations within the one setting to
accurately predict risk of falling [133] At the time of publication there
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
59Queensland Stay On Your Feetreg community good practice guidelines
is no evidence available to make it possible to recommend a risk
assessment tool for use in all subpopulations within community
settings However falls prevention resources for general use which are
available from the Victorian Department of Human Services Aged Care
Branch website httpwwwhealthvicgovauagedcaremaintaining
fallsindexhtm were reviewed and recommended by the National
Ageing Research Institute in 2005
Tool selection should depend upon knowing the time required to
complete the tool recommended cut-off scores (including the cut-
off score which the predictive validity was tested against) and the
necessary equipment and training A 70 percent cut-off for sensitivity
and specificity indicates a lsquohighrsquo predictive value [143] Predictive values
may only be applicable for screening tools There is debate around the
requirement of sensitivity and specificity for assessment tools using
evidence-based risk factors to inform interventions For an explanation
of the terms for assessing validity of tools please refer to the Glossary
Examples of falls screening and assessment tools can be found in the
following Section 65
Measurement Tools65
Some of the most commonly used tools are discussed in the following
sections
Falls Risk Awareness Tools651
There are a number of consumer booklets available to raise public
awareness of falls risk in older people Most are available in
other languages as well as English Unlike falls risk screening and
assessment tools they do not provide predictive risk but rather self
reported risk
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
60 Queensland Stay On Your Feetreg community good practice guidelines
General information resources for consumers include
How to Stay On Your Feet Eacute reg Checklist Developed by Queensland
Health and available at httpwwwhealthqldgovau
stayonyourfeet
Staying on Staying active and independent in your home A guide Eacute
and checklist for staying independent and reducing your risk of
injury from falling Queensland Health Home and community Care
(HACC) resource available at httpwwwhealthqldgovauhacc
HACCMulti_fallsprevasp
One step ahead Preventing falls A guide for older people Eacute
Queensland Health and Department of Housing resource available
at httpwwwhealthqldgovauPHSDocumentsshpu22094pdf
Donrsquot fall for it Falls can be prevented A guide to preventing falls Eacute
for older people Developed as part of the National Falls Prevention
in Older People Initiative and available at httpwwwhealthgov
auinternetwcmspublishingnsfContenthealth-pubhlth-strateg-
injury-falls-documentshtm
Stay on your feet and avoid a shattering experience Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls prevention booklet Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
DVA Homefront guide to preventing falls for older people Eacute Developed
by the National Ageing Research Institute httpwwwdvagovau
mediapublicat2006preventing_fallspreventing_fallspdf
Short self-assessment checklists for personal risk factors include
Will I stay active and independent Eacute Developed by Queensland Health
httpwwwhealthqldgovaustayonyourfeet
How safe are you from falling Eacute Developed by Stay on Your Feet -
Adelaide West and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
61Queensland Stay On Your Feetreg community good practice guidelines
How many of these questions do you fall down on Eacute Developed by
Stay on Your Feetreg WA and available at httpwwwstayonyourfeet
comauresourcesphp
Falls are preventable Eacute Developed for Department of Human Services
Victoria and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Am I at risk of falls Quick quiz Eacute Developed for Department of Human
Services Victoria and available at httpwwwhealthvicgovau
agedcaremaintainingfallsindexhtm
In addition to personal falls risk awareness a number of checklists are
available to audit the safety of the environment particularly the home
Consumer resources for home safety checklists include
Stay on Your Feet Your home safety checklist Eacute Developed by NSW
Health and available at httpwwwhealthvicgovauagedcare
maintainingfallsindexhtm
Your home safety checklist Eacute Developed by Stay on Your Feetreg WA
and available at httpwwwstayonyourfeetcomauresourcesphp
Resources for auditing public spaces include
Improving safety to promote walking in your local area Eacute Developed
for Department of Human Services Victoria and available at http
wwwhealthvicgovauagedcaremaintainingfallsdownloads
imprsafety_promotewalkpdf
Preventing falls in public places Appendix C Hazards Report Form Eacute
Developed by NSW Stay on Your Feet Program and available at
httpwwwhealthvicgovauagedcaremaintainingfallslocalgov_
publichtm
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
62 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk Screening Tools652
Below are listed a number of examples of screening tools with
reasonable sensitivity and specificity4 determined for well-conducted
studies with adequately-sized samples A number of these tests or a
battery of tests may be used in combination to measure falls risk in
any one patient
Alternate Step Test This test is easy to do and only requires a small
amount of additional equipment (step and stop watch) It should be
done with shoes removed and using a step that is 19cm high and
40 cm deep The test requires weight shifting by stepping alternately
with the whole left foot and then right foot up onto the step as fast
as possible The test is the time to complete eight steps alternating
the feet Tiedemann et al (2007) found the sensitivity of this test was
69 percent and specificity 65 percent and with a cut off point of 10
seconds is associated with a 130 percent increased falls risk and
identifies multiple fallers [145]
Sit to Stand with five repetitions (STS-5) This test is used to measure
lower limb strength [145] This task requires getting up from a standard
height sitting position five times from a chair (height 43cm) without
arm rests Tiedemann et al (2007) found the sensitivity of this test
was 66 percent and specificity 55 percent and at a cut off point of 12
seconds it could significantly predict subjects who suffered multiple
falls [145]
6 ndash Metre Walk The six metre walk test is the time taken in seconds
to walk six metres at normal walking speed A two metre approach
and a further two metres beyond the six metre distance ensures that
walking speed is constant across the timed six metres Tiedemann et al
4 An important issue when comparing sensitivity and specificity figures is the sampling used ndash many studies have used those clearly at risk and those clearly not at risk (eg well older people) and so discriminating them is relatively easy The best studies of sensitivity specificity include a moderate proportion of the sample in the middle ground who are much harder to classify Caution needs to be used in comparing these multiple studies of sensitivity and specificity so that for direct comparison studies with similar sampling profile should be used
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
63Queensland Stay On Your Feetreg community good practice guidelines
(2007) found the sensitivity of this test was 50 percent and specificity
68 percent The test had strong external validity (it was able to
discriminate between multiple fallers and non-multiple fallers) which
made the tool a significant predictor of falls risk [145]
Functional Reach This test involves the measurement of a subjectrsquos
ability to reach forward as far as possible without losing balance or
stepping and with the arm positioned at 90 degrees of shoulder
flexion At a cut-off score of 20 centimetres reported sensitivity was 73
percent and specificity was 88 percent [146]
Elderly Fall Screening (EFST) is a five item test used to divide subjects
into low and high risk based on history of falls and observations of
walking speed and gait style [147] Cwikel et al (1998) demonstrated that
the results of physiciansrsquo examinations corroborated the EFST results
in 75 percent of the cases with 83 percent sensitivity and 69 percent
specificity for a cut-off score of two or more risk items [147]
Geriatric Postal Screening Survey (GPSS) is a ten item screening
tool Five of the items screen for specific geriatric conditions (falls
balance problems urinary incontinence depression memory loss
and functional impairment) and five other items are general indicators
of health status (health perceptions weight loss polypharmacy and
pain) [148] The screening accuracy of the GPSS compared with clinical
evaluation for falls risk showed 94 percent sensitivity and 51 percent
specificity using four as the cut-off point [148]
QuickScreen measures number of risk factors based on tests of vision
(low contrast visual acuity test) peripheral sensation (tactile sensitivity
test) strength reaction time and balance (near tandem stand
alternate step and sit-to-stand tests) [35] The criteria for identifying
impairments that increase risk of falls were identified from prospective
studies of community-dwelling older people [149] When participants in a
validation study were stratified into high and low risk groups (high risk
being the identification of four or more QuickScreen risk factors) the
sensitivity was 74 percent and the specificity was 63 percent [150]
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
64 Queensland Stay On Your Feetreg community good practice guidelines
Falls Risk for Older People ndash Community Setting Screen (FROP-Com Screen) The FROP-Com Screen is a three-item screen that has been
developed based on the FROP-Com (see Section 6531) Recent
research found the sensitivity ranged from 067 ndash 070 The results
provide another validated risk screening tool for use in the community
For more information refer to httpwwwmednwhunimelbeduau
researchresearch_falls_servicehtm
Timed Up and Go (TUG) For this test the participant sits in a chair
with arms On the word ldquogordquo the participant is required to stand and
walk at a normal pace for three metres turn around walk back and sit
back down As a predictor of falls this test demonstrated a sensitivity
of 86 percent and specificity of 71 percent using a cut-off score of 10
seconds [151] This has been recommended by the American Geriatrics
Society and British Geriatric Society [59]
Falls Risk Assessment Tools653
Multifactorial Falls Risk Assessment6531
Examples of multifactorial falls risk assessment tools include
Physiological Profile Assessment (PPA) [152] involves quantitative
assessment of sensorimotor and balance abilities It also includes
simple tests of vision (high and low contrast visual acuity contrast
sensitivity depth perception) peripheral sensation (tactile sensitivity
vibration sense proprioception) lower limb strength reaction time
and postural sway The comprehensive version of the PPA contains 18
items and takes 45 minutes to administer It has been used primarily
in dedicated falls clinics and research settings The shorter version
of the PPA takes 15 minutes to administer and contains five items a
single assessment of vision peripheral sensation lower limb strength
reaction time and body sway The shorter version has been used
more extensively in clinical practice In a study of community-dwelling
women [149] the PPA measurements correctly classified subjects into
a multiple falls group or non-multiple falls group with 75 percent
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
65Queensland Stay On Your Feetreg community good practice guidelines
accuracy There is a cost involved to purchase these tools Details
about the instrument are available at httpwwwpowmrieduau
FBRG
Falls Risk for Older People ndash Community Setting (FROP-Com) grades
risk on most falls risk factors on a 4 point scale there is no cost
associated with this tool it takes about 20 minutes to complete
and it has guidelines that will assist with assessment and for
recommendations to guide falls management The falls risk factors
included are falls history medications medical conditions sensory
loss foot problems cognitive status continence nutritional status
and function In a study using the FROP-Com [153] the assessment
tool identified a high overall falls risk score for a group of individuals
presenting to a hospital Emergency Department after a fall Details
about the instrument are available at httpwwwhealthvicgovau
agedcaremaintainingfallsprovidershomefrophtm
Balance Assessment6532
Below are a number of commonly used examples of balance
assessments requiring little or no equipment
Berg Balance Scale (BBS) consists of 14 items which include tasks
such as transfers standing unsupported sit-to-stand tandem
standing turning 360 degrees and single-leg stance [154] Overall the
Berg Balance Scale has moderate to good specificity but low sensitivity
in predicting falls [35] However in a study combining the score on
the BBS with a self- reported history of imbalance sensitivity was 91
percent and specificity was 82 percent [155]
Tinettirsquos Performance Oriented Balance and Mobility Assessment (POMA) is designed to assess balance and gait during position
changes and gait manoeuvres used during normal activities
Performance on 14 balance items and 10 gait items is graded as
normal adaptive or abnormal [156 157] The balance assessment
evaluates sitting balance rising from a chair immediate and prolonged
standing balance withstanding a nudge to the sternum balance with
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
66 Queensland Stay On Your Feetreg community good practice guidelines
eyes closed turning balance and sitting down In a validity study the
Tinetti balance scale was used to predict individuals who would fall at
least once during the following year [156] A cut-off score of 36 or less
had 70 percent sensitivity and 52 percent specificity for predicting
fallers
Home hazard assessment6533
Instruments have been developed for use by community nursing
personnel occupational therapists and physiotherapists to identify
hazards in the home that may contribute to or increase the risk
of falling The content validity of some of these tools has been
established [158 159] The HomeFast Tool demonstrated fair to good
level of inter-rater agreement (62) for the identification of home
hazards [159] Details about the instrument are available at httpwww
healthvicgovauagedcaremaintainingfallsprovidershomeenv_
checkhtm
Comprehensive geriatric assessments 6534
While not designed primarily as a falls risk assessment tool falls
history is generally included in comprehensive geriatric assessments
Also included are many of the known risk factors for falls such as
cognitive status sensory impairments pain weight loss incontinence
effects of medication use and mobility impairment In addition
comprehensive assessment may include lifestyle factors such as
alcohol consumption smoking history diet physical activity and
social support
Examples of health assessments for older community-dwelling people
include
Enhanced Primary Care (EPC) Health Assessments for Australians Eacute
aged 75 + (55 + for Aboriginal and Torres Strait Islander people)
httphealthgovauinternetwcmspublishingnsfContent
health-epc-hlthassmnthtm$FILEchklisthlthpdf
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
67Queensland Stay On Your Feetreg community good practice guidelines
Royal Australian College of General Practitioners (RACGP) Health Eacute
Assessment httpwwwtdgpcomauforms75YOHealthAssessme
ntRACGPVersionOct2006rtf
Aboriginal and Torres Strait Islanders Health Assessment Eacute httpepc
adgpcomauresourcesdownloadhealthassTSI04purpledoc
InterRAI assessment tools for geriatric screening and care planning Eacute
across the continuum of care httpinterrai-auorg
Falls Evaluation Checklist for General Practitioners Eacute httpwww
healthvicgovauagedcaremaintainingfallsprovidershome
prachtm
As part of health assessments other associated factors may also
be assessed such as nutritional status cognitive ability and social
support Examples of pre-existing scales often included in health
assessments [160] include
Nutrition The Australian Nutrition Screening Initiative (ANSI) Eacute [161] is a
12 item screening tool that asks about eating habits and conditions
associated with nutrition risk It is not intended to diagnose
malnutrition
Cognitive Impairment The 11 item Mini-Mental Status Eacute
Examination [162] and an abbreviated form using four items [163]
are commonly used clinical screening tests to assess cognitive
impairment in older adults
Social Support The 11 item Dukes Social Support Index measures Eacute
social interaction (four items) and satisfaction with support (seven
items) and provides a brief and valid measure of social support for
use in community-dwelling older people [164 165]
Depression The Geriatric Depression Scale (GDS) Eacute [166] has been
tested extensively in the older population Short versions (four five
and 15 item) are useful screening tools in the clinical setting for the
assessment of depression [167]
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
68 Queensland Stay On Your Feetreg community good practice guidelines
Suggested tools for these measures are available in the Stay On Your
Feetreg Community Good Practice Toolkit at wwwhealthqldgovau
stayonyourfeet Currently there is no information on sensitivity and
specificity for these tools for falls prediction
The lack of studies on the predictive validity of comprehensive medical
assessments likely reflects the fact that such assessments are not
undertaken to predict falls risk but to identify areas where medical
intervention is required [132]
The Assessor66
To achieve a comprehensive and meaningful assessment the assessor
must
be trained in the assessment tool Eacute
understand the measurements used within the tool including Eacute
normative scores for older people of different ages
have good communication skills knowledge and experience in the Eacute
care of older people
understand ageing across the lifespan (including heterogeneity of Eacute
older people their culture their environment and interaction within
the community)
involve the client and where appropriate the carer in discussion of Eacute
assessment findings implications and a management plan
Recommended Pathways for the Measurement of Falls 67 Risk
The recommended pathways for measurement of falls risk are shown in
Figure 61
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
69Queensland Stay On Your Feetreg community good practice guidelines
Figure 6‑1 Recommended Pathways for Measurement of Falls Risk
Source Adapted from American Geriatric Society Guidelines 2001 (p666) [59]
Popu
lati
on
Falls
Ris
k M
easu
rem
ent
Wel
l Age
d
Awar
enes
s Ra
isin
g
Vuln
erab
le
Scre
enin
g
Hig
h Ri
sk
Asse
ssm
ent
Opp
ortu
nist
ic
com
mun
ity
falls
aw
aren
ess
rais
ing
Peri
odic
cas
e fin
din
g in
pri
mar
y h
ealt
h c
are
Pati
ent p
rese
nts
to m
edic
al fa
cilit
y af
ter a
fall
No
falls
no
iden
tifie
d ri
sks
Sin
gle
fall
id
enti
fied
as
lsquoa
t ris
krsquo
Recu
rren
t fal
ls
iden
tifie
d ri
sks
No
pro
blem
Ch
eck
for g
ait a
nd
bal
ance
pro
blem
s E
g u
se T
UG
Gai
t and
b
alan
ce
pro
blem
s
Unt
arge
ted
mul
tifa
ctor
ial
hea
lth
pro
mot
ion
pro
gram
sFa
lls R
isk
Ass
essm
ent
Targ
eted
mul
tifa
ctor
ial
falls
pre
vent
ion
pro
gram
s
As
a m
inim
um a
sk ldquo
Hav
e yo
u h
ad a
fall
in th
e la
st
12 m
onth
srdquo
and
pre
fera
bly
follo
w-u
p w
ith
a
scre
enin
g to
ol
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
70 Queensland Stay On Your Feetreg community good practice guidelines
Good Practice Points
A minimum falls risk screen would be the single item question EacuteldquoHave you had a fall in the last 12 monthsrdquo
At least annually health professionals should ask all older people Eacutein their care about the occurrence of recent falls
All older people who report a fall should be observed for gait and Eacutebalance problems for example using the Timed Up and Go (TUG) Those that have difficulty or demonstrate unsteadiness need further assessment of their falls risk
Any assessment of falls risk should be followed by action to Eacutedevelop a tailored plan to prevent falls with a focus on identified risk factors
Falls risk assessment needs to be undertaken by trained staff with Eacuteintermittent reviews to ensure appropriate and consistent use
Where possible select tools that have been validated in the target Eacutepopulation
Adapting or modifying these tools is not recommended Eacute
Any design or innovation in falls risk assessment tools should be Eacuteundertaken in a research context to ensure appropriate evaluation of the tool Ideally the results should be published in a peer-review journal
Available evidence at the time of publication does not make Eacuteit possible to recommend a risk assessment tool for use in all subpopulations within community settings However a set of resources for preventing falls for general use are available from the Victorian Department of Human Services Aged Care Branch website httpwwwhealthvicgovauagedcaremaintainingfallsindexhtm These were reviewed and recommended by the National Ageing Research Institute in 2005
A number of tools for assessing risk factors in older community- Eacutedwelling people are available in the Queensland Stay on Your Feetreg Community Good Practice Toolkit (httpwwwhealthqldgovaustayonyourfeet)
There should be wide dissemination of self check lists and health Eacutepromotion information with relevance to preventing falls
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
71Queensland Stay On Your Feetreg community good practice guidelines
Attitudes of Older People About Falls and Falls 68 Prevention
Research findings about knowledge attitudes andor information
needs of older community-dwelling people have the following
implications for preventing falls
Perception of being lsquooldrsquo681
There is a need to recognise that lsquoolder peoplersquo represent a large and
very diverse group [69] Targeting lsquoolder peoplersquo as a homogeneous
group may provoke a negative or non-response among people who do
not relate to portrayals with which they do not identify [68] People may
distance themselves from the possibility of a fall and involvement in
prevention initiatives through fear of stigma and stereotyping as being
lsquooldrsquo [168] Prevention messages need to be framed in positive terms and
be built into ongoing health assessments The information should be
included in lifestyle programs such as retirement planning and chromic
disease strategies
Perception of the Language of Falls682
The term lsquofallrsquo is contentious has negative connotations and its use
is likely to inhibit engagement with any preventive program [68] as
well as signify an admission of being lsquooldrsquo [69] lsquoFalls preventionrsquo is
an unfamiliar term [69] but predominantly associated with fixing or
removal of hazards for example repair of broken footpaths or removal
of floor rugs [69 168 169] To improve the likelihood of being taken up
by older people messages should focus on positive healthy ageing
highlighting independence staying in control and living in onersquos home
for longer [69]
Perception of Falls Risk683
Older people are not ignorant of risks [170] and acknowledge that falls
are a problem with serious consequences [69 169] However they do not
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
72 Queensland Stay On Your Feetreg community good practice guidelines
necessarily consider themselves at risk [69 168 169 170] unless they have
experienced a fall [69 171] Falls are generally regarded as a future risk
and not a current concern and are mostly not considered important at
younger ages [169] People tend to consider that ldquootherrdquo older people
are more at risk than themselves [169] Social and cultural differences
in acceptance of the ageing process can also influence perceptions of
risk vulnerability and dependence [68] There is disbelief among older
people that the risk of falling can be reduced [69] because falls are seen
as inevitable unpredictable and not preventable [68 172]
Attribution of Falls Risk684
Falls are often attributed to external factors [169] such as bad luck or
the incompetence of others [168] Perceived causes of falls may relate to
health status those in good health are likely to attribute their fall to
their surroundings while those with compromised health are likely to
attribute their fall to their own limitations [173]
Information Needs685
Information should counter the belief that falls are inevitable and that
nothing can be done [70] Such information can come from a variety of
sources [69] and should be published in different languages [70] Advice
on preventing falls is typically regarded as common sense potentially
patronising and useful in principle but only necessary for older more
disabled individuals [170]
Relevance of Participating in Programs to Prevent 686 Falls
The perceived relevance of participating in interventions to prevent
falls is low until a fall has been experienced [68 69 171] For younger
people in the over 65 age group falls may not be perceived to be a
current concern and the relevance of preventing falls must relate
to their particular context [68] Persons with the poorest physical
cognitive and psychological functional abilities represent the part of
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
73Queensland Stay On Your Feetreg community good practice guidelines
the population at highest risk of falling ndash yet these people are often
difficult to reach with activities to prevent falls [174]
To make preventing falls more relevant and encourage participation
the emphasis should be on the positive actions and sense of mastery
to counteract fear of falling [172] as well as the multiple and positive
benefits for health and well-being [170] The promotion of healthy
ageing may be more attractive and appropriate to all age groups [68]
Falls interventions need to be communicated as a lifestyle-enhancing
measure and as a means for staying independent for longer [69 70]
Awareness of health problems that relate to falls (such as
osteoporosis) represents a possible route for discourses about
preventing falls [68] and is relevant for fallers and non-fallers
Finding ways to enhance confidence social activity and promote
independence may be particularly effective in facilitating change
among those groups for whom falls and indeed old age are perceived
to be a distant risk [69 172]
Yardley et al (2007) examined ways for promoting uptake of and
adherence to falls-prevention interventions among older people
based on literature review clinical experience of the core group
members and substantial qualitative and quantitative studies of older
peoplersquos views [175] Recommendations address the need to educate
the public to ensure that interventions are compatible with a positive
identity to tailor interventions to the specific situation and values of
the individual and to use validated methods to maintain longer-term
adherence
Black and Hill (2005) examined ways to improve the uptake of
interventions at falls clinics in Victoria [176] They found that people
thought interventions were not needed were of minimal benefit
and were inappropriate People in the study also thought that the
interventions aggravated injuries their health had declined and in
some cases there was miscommunication due to a language barrier
This report highlighted the need for health professionals to clearly
explain the benefit of the intervention and to consider a personrsquos
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care
74 Queensland Stay On Your Feetreg community good practice guidelines
perspective current circumstances and provide a holistic person
centered approach to care [176]
Good Practice Points
Prior to embarking on falls risk assessment and intervention the Eacuterelevance and acceptability of interventions to the target group should be understood
Public education programs should promote greater awareness Eacuteamong older people carers and health professionals of the benefits of preventive health activities
Programs should be flexible enough to accommodate older Eacutepeoplersquos needs circumstances and interests
In discussions with older people the term lsquofalls preventionrsquo Eacuteshould be down played as it may be unfamiliar difficult to understand or not considered relevant Messages for preventing falls should be presented in the context of staying independent for longer
Information provided should be easy to understand so that older Eacutepeople and their carers can take part in discussions and decisions about preventing falls This includes offering information in languages other than English if appropriate or necessary
Find out what changes an older person is willing to make to Eacuteprevent falls and help overcome potential barriers that may prevent action to reduce falls
Clearly explain the benefits of the intervention and consider Eacutethe personrsquos perspective current circumstances and provide a holistic person centered approach to care